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Assessment of the Heart, Great Assessment of the Heart, Great vessels of the neck, and vessels of the neck, and Peripheral Vascular system Peripheral Vascular system Rachel S. Natividad, RN,MSN

Heart & Neck Vessel & Peripheral Vascular Assessment

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Heart & Neck Vessel & Peripheral Vascular Assessment

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Page 1: Heart & Neck Vessel & Peripheral Vascular Assessment

Assessment of the Heart, Great vessels Assessment of the Heart, Great vessels of the neck, and Peripheral Vascular of the neck, and Peripheral Vascular

systemsystem

Rachel S. Natividad, RN,MSN

Page 2: Heart & Neck Vessel & Peripheral Vascular Assessment

Position in the ChestPosition in the Chest

Beneath precordium—area on Beneath precordium—area on anterior chest overlying the anterior chest overlying the heart and great vesselsheart and great vessels

Located in mediastinum—Located in mediastinum—middle third of chest—middle third of chest—between the lungsbetween the lungs

Page 3: Heart & Neck Vessel & Peripheral Vascular Assessment

Heart is an Heart is an upside down upside down triangle in the triangle in the chestchest

Top of heart isTop of heart is BaseBase, bottom , bottom is is ApexApex

Page 4: Heart & Neck Vessel & Peripheral Vascular Assessment

Extends from Extends from 2nd to 5th ICS 2nd to 5th ICS and from Rt and from Rt sternal border sternal border to Lt MCLto Lt MCL

Great vessels Great vessels above base of above base of heartheart

Page 5: Heart & Neck Vessel & Peripheral Vascular Assessment

Great vessels of the neckGreat vessels of the neck Jugular veinsJugular veins

Carotid arteriesCarotid arteries

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JUGULAR VENOUS DISTENTION

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JVDJVD

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Anatomy of the HeartAnatomy of the Heart

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AssessmentAssessment

Position client Position client supinesupine ThenThen head elevated at 45 degrees head elevated at 45 degrees

INSPECTION:INSPECTION: Lifts, heavesLifts, heaves PMI (assess location)PMI (assess location)

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PalpationPalpation

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Physical LandmarksPhysical Landmarks

Suprasternal Suprasternal notchnotch

SternumSternum Manubriosternal Manubriosternal

angle – Angle of angle – Angle of LouisLouis

Intercostal Intercostal SpacesSpaces

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Auscultation: Auscultation: Auscultatory SitesAuscultatory Sites

Page 13: Heart & Neck Vessel & Peripheral Vascular Assessment

Auscultatory Sites: Cont.Auscultatory Sites: Cont.

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Heart Sounds – S1…(Lub)…Heart Sounds – S1…(Lub)…

S1: Closure of AV S1: Closure of AV valves (mitral and valves (mitral and tricuspid valves: tricuspid valves: M1 before T1)M1 before T1)

Correlates with the Correlates with the carotid pulsecarotid pulse

Can be split but not Can be split but not oftenoften

Page 15: Heart & Neck Vessel & Peripheral Vascular Assessment

Heart Sounds – S2…(Dub)…Heart Sounds – S2…(Dub)…

S2: Closure of S2: Closure of Semilunar valves Semilunar valves (aortic & pulmonic) (aortic & pulmonic)

May have a split May have a split sound (A2 before sound (A2 before P2)P2)

Page 16: Heart & Neck Vessel & Peripheral Vascular Assessment

Heart Sounds – Cont.Heart Sounds – Cont.

Base (R/L 2nd ICS)Base (R/L 2nd ICS)– S2 louder than S1S2 louder than S1

Apex Apex – S1 louder than S2S1 louder than S2

Normal physiologic S2 Normal physiologic S2 SplitSplit– Best heard at pulmonic Best heard at pulmonic

area area during inspirationduring inspiration

Fixed split (no variation Fixed split (no variation with inspiration)with inspiration)

Page 17: Heart & Neck Vessel & Peripheral Vascular Assessment

Extra Heart SoundsExtra Heart SoundsS3…S3… Due to Rapid Due to Rapid

ventricularventricular filling: filling: ventricular gallopventricular gallop

S1 -- S2-S3 (Ken--tuc-S1 -- S2-S3 (Ken--tuc-ky) ky)

S4…S4… Due to slow ventricular Due to slow ventricular

contraction: atrial contraction: atrial gallopgallop

S4-S1 — S2 (Ten-nes—S4-S1 — S2 (Ten-nes—see)see)

Page 18: Heart & Neck Vessel & Peripheral Vascular Assessment

MurmursMurmurs

Grade IGrade I :barely audible :barely audible Gr II :Gr II : audible but audible but

quiet and softquiet and soft Gr IIIGr III : moderated : moderated

loud, without thrust or loud, without thrust or thrillthrill

Gr IVGr IV : loud, with thrill : loud, with thrill Gr VGr V : louder with thrill, : louder with thrill,

steth on chest wallsteth on chest wall Gr VIGr VI : loud enough to : loud enough to

be heard before steth be heard before steth on cheston chest

turbulent blood flow turbulent blood flow within the heartwithin the heart

Listen for murmurs in Listen for murmurs in the same auscultatory the same auscultatory sites APETMsites APETM

Page 19: Heart & Neck Vessel & Peripheral Vascular Assessment

Peripheral Vascular Peripheral Vascular AssessmentAssessment

Skin tempSkin temp ColorColor PulsesPulses Cap refillCap refill edemaedema

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Peripheral PulsesPeripheral Pulses

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Documentation of PulsesDocumentation of Pulses

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Capillary RefillCapillary Refill

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EdemaEdema

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Pitting edemaPitting edema

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Assessing for EdemaAssessing for Edema

Depress Depress

pretibial area pretibial area & medial & medial malleolusmalleolus for for 5 5 secondsseconds

Grade pitting Grade pitting edemaedema1+ to 4+1+ to 4+

Page 26: Heart & Neck Vessel & Peripheral Vascular Assessment

Deep Vein Thrombosis Deep Vein Thrombosis (DVT)(DVT)

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Assessment Guide: Gas Assessment Guide: Gas TransportationTransportation

Blood Pressure: 128/64, 132/72Apical Heart Rate: 80, 74Peripheral Pulse:

Radial rate: 78, 74Rhythm: regular, irregularStrength: strong, weak, thready, bounding,0-+4Rt. Pedal pulse: 2+Lt. Pedal pulse: 2+Edema: present, noneEdema: present, none

Degree: 1+, 2+Degree: 1+, 2+Location: LLE, RUELocation: LLE, RUE

Page 28: Heart & Neck Vessel & Peripheral Vascular Assessment

Cap refillCap refill– Upper extremities: 2 secUpper extremities: 2 sec– Lower extremities: 2 secLower extremities: 2 sec

Skin/Mucous Membranes: Other Skin/Mucous Membranes: Other (bleeding, infection)(bleeding, infection)– Skin /mucous membranes pinkSkin /mucous membranes pink– note vascular lesions (purpura, note vascular lesions (purpura,

ecchymoses, petechiae)ecchymoses, petechiae)– redness and inflammationredness and inflammation– Interventions in useInterventions in use

Venodyne/leg compression machine; Venodyne/leg compression machine; elevated LEs on pillow; thigh high elevated LEs on pillow; thigh high tedhose in usetedhose in use

Med List: Digoxin, Atenolol, Zestril, etc.Med List: Digoxin, Atenolol, Zestril, etc.

Page 29: Heart & Neck Vessel & Peripheral Vascular Assessment

ArmsArms NORMAL FINDINGSNORMAL FINDINGS DEVIATION FROM DEVIATION FROM NORMALNORMAL

Inspection1. Observe arm size & venous pattern; also look for edema

Arms are bilaterally symmetric with minimal variation in size and shape.

No edema or prominent venous patterning

Lymphedema – results from blocked lymphatic circulation, which may be caused by breast surgery

Lymphedema – affects 1 extremity, causing induration and nonpitting edema.

Prominent venous patterning with edema – venous obstruction

Peripheral Vascular AssessmentPeripheral Vascular Assessment

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ArmsArms NORMAL FINDINGSNORMAL FINDINGS DEVIATION FROM DEVIATION FROM NORMALNORMAL

Inspection2. Observe coloration of the hands and arms.

Color varies depending on the client’s skin tone, although color should be the same bilaterally.

Raynaud’s disease Vascular disorder caused by vasoconstriction of the fingers or toesCaused by rapid changes of color (pallor, cyanosis, and redness), swelling, pain, numbness, tingling, burning, throbbing, & coldness.Occurs bilaterally; symptoms last minutes to hours

Peripheral Vascular AssessmentPeripheral Vascular Assessment

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ArmsArms NORMAL FINDINGSNORMAL FINDINGS DEVIATION FROM DEVIATION FROM NORMALNORMAL

Palpation1. Palpate the client’s fingers, hands, and arms, and note the temperature..

Skin is warm to touch bilaterally

Cool extremity – sign of arterial insufficiency.

Cold fingers and hands – common in Raynaud’s disease.

Peripheral Vascular AssessmentPeripheral Vascular Assessment

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ArmsArms NORMAL FINDINGSNORMAL FINDINGS DEVIATION FROM DEVIATION FROM NORMALNORMAL

Palpation2. Palpate to assess capillary refill time (CRT). Compress the nailbed until it blanches.Release the pressure and calculate the time it takes for color to return.Indicates peripheral perfusion and reflects cardiac outputCLINICAL TIP: X findings – rm temp is cool, pt has edema, anemia, or recently smoked a cigar

Capillary bed refill (and therefore color returns) in 1-2 sec.

CRT greater than 2 seconds: (1) vasoconstriction (2) decreased CO (3) shock (4) arterial occlusion (5) hypothermia

Peripheral Vascular AssessmentPeripheral Vascular Assessment

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ArmsArms NORMAL FINDINGSNORMAL FINDINGS DEVIATION FROM DEVIATION FROM NORMALNORMAL

Palpation3. Palpate the radial pulse.Gently press the radial artery against the radius.CLINICAL TIP: For difficult-to-palpate pulses, use a Doppler ultrasound device.

Radial pulses have equal strength bilaterally (2+). Artery walls have a resilient quality (bounce)

Increased radial pulse (1) hyperkinetic stateDiminished or absent radial pulse (1) Partial or complete arterial occlusion (more common in legs than in the arms) (2) Buerger’s disease (3) Scleroderma*Obliteration of the pulse may result from compression by external sources, as in compartment syndrome

Peripheral Vascular AssessmentPeripheral Vascular Assessment

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Buerger’s Disease

Page 39: Heart & Neck Vessel & Peripheral Vascular Assessment

The initial symptoms of Buerger’s Disease often include claudication (pain induced by insufficient blood flow during exercise) in the feet and/or hands, or pain in these areas at rest. The pain typically begins in the extremities but may radiate to other (more central) parts of the body. Other signs and symptoms of this disease may include numbness and/or tingling in the limbs and Raynaud’s phenomenon (a condition in which the distal extremities — fingers, toes, hands, feet — turn white upon exposure to cold). Skin ulcerations and gangrene (pictured below) of the digits (fingers and toes) are common in Buerger’s disease. Pain may be very intense in the affected regions.

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ArmsArms NORMAL FINDINGSNORMAL FINDINGS DEVIATION FROM DEVIATION FROM NORMALNORMAL

Palpation4. Palpate the ulnar pulse.Not routinely assessed bec. they are located than radial pulses and are difficult to dectect.Done if you suspect arterial insufficiency

Ulnar pulses may not be detected.

Lack of resilience or inelasticity of the artery - arteriosclerosis

Peripheral Vascular AssessmentPeripheral Vascular Assessment

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ArmsArms NORMAL FINDINGSNORMAL FINDINGS DEVIATION FROM DEVIATION FROM NORMALNORMAL

Palpation5. Palpate the epithrochlear lymph nodes.Take the client’s left hand in your right hand as if you were shaking hands.Flex the client’s elbow about 90 degrees.Use your left hand to palpate behind the elbow in the groove between the biceps and triceps muscles.If nodes are detected, evaluate for size, tenderness, and consistency

Normally not palpable. Enlarged nodes (1) infection in the hand or forearm (2) may occur w/ generalized lymphadeno- pathy (3) lesion in the area

Peripheral Vascular AssessmentPeripheral Vascular Assessment

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ArmsArms NORMAL FINDINGSNORMAL FINDINGS DEVIATION FROM DEVIATION FROM NORMALNORMAL

Palpation7. Perform the Allen Test.Evaluates patency of the radial or ulnar arteries.Done when patency is questionable or before procedures such as a radial artery puncture.Begins by assessing the ulnar patency.Have pt rest hand palm side up on the exam table and make a fist.

Pink coloration returns to the palms within 3-5 seconds if the ulnar artery is patent.Pink coloration returns within 3-5 seconds if the radial artery is patent.

Arterial insufficiency or occlusion of the ulnar & radial artery – pallor persists,

Peripheral Vascular AssessmentPeripheral Vascular Assessment

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ArmsArms NORMAL FINDINGSNORMAL FINDINGS DEVIATION FROM DEVIATION FROM NORMALNORMAL

Palpation7. Perform the Allen Test.To assess radial patency, repeat the procedure as before, but at the last test, release pressure on the radial artery.

Peripheral Vascular AssessmentPeripheral Vascular Assessment

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ArmsArms NORMAL FINDINGSNORMAL FINDINGS DEVIATION FROM DEVIATION FROM NORMALNORMAL

Palpation7. Perform the Allen Test.Evaluates patency of the radial or ulnar arteries.Done when patency is questionable or before procedures such as a radial artery puncture.Begins by assessing the ulnar patency.Have pt rest hand palm side up on the exam table and make a fist.

Peripheral Vascular AssessmentPeripheral Vascular Assessment

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LegsLegs NORMAL FINDINGSNORMAL FINDINGS DEVIATION FROM DEVIATION FROM NORMALNORMAL

Palpation1. Palpate the superficial inguinal lymph nodes.

Nontender movable lymph nodes up to 1 or even 2 cm are commonly palpated.

Lymph nodes larger than 2 cm with or without tenderness (lymphadenopathy)

(1) local infection (2) generalized lymphadenopathy Fixed nodes -

malignancy

Peripheral Vascular AssessmentPeripheral Vascular Assessment